Get Highmark Enr-164 2020-2025

Filling out the Highmark ENR-164 form is an essential step for managing changes to your health coverage. This guide provides detailed instructions to help you navigate each section of the form with confidence.

Follow the steps to complete the Highmark ENR-164 form online.

1. Click ‘Get Form’ button to access the ENR-164 form and open it in the editor.
2. Begin by entering the 'Employee/Contract Holder Information'. Fill in details like the effective date, employer/group name, and group number. Be sure to check the reason for completion box that applies to your situation.
3. Proceed to 'Dependent Changes'. Indicate any additions or cancellations of dependents resulting from life events such as birth, marriage, or divorce. Include the date of the event to validate the change.
4. In the 'Other Changes' section, update any personal information that may have changed, such as your name or address. If you are changing to Medicare eligibility or altering your coverage, specify the date of the event.
5. Input your personal information in the required fields, including first name, middle initial, last name, social security number, date of birth, age, and address details.
6. Fill in the coverage options you require, including medical, vision, and dental products. Confirm your employment status and provide the home/cell phone number.
7. If you have dependents, provide their information in the 'Covered Dependent Information' section. Include all required details for spouses, domestic partners, and children, along with verification documents if necessary, such as marriage certificates or custody papers.
8. Complete the 'Other Health Insurance Coverage' area if applicable. Include details of any other insurance coverage and the relationship to the policyholder.
9. Review your entries for accuracy. Once verified, complete the authorized signature section by entering your name to create an electronic signature acknowledging the truth of your statements.
10. After completing the form, save your changes. You may then download, print, or share the form as needed.

Begin your document submission online to ensure timely processing of your information.